In 2018, the Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) published these guidelines for treating patients with bipolar disorder.
According to the guidelines, the first-line treatment is psychoeducation, which is provided either individually or in a group setting. Michalak noted that psychoeducation typically includes educating the person with bipolar disorder and/or their family about the nature of the illness, its treatments, and key coping strategies.
The second-line treatment is either cognitive-behavioral therapy (CBT) or family-focused therapy (FFT). Both treatments are used as maintenance therapies, and may be helpful for people who are currently depressed.
Brosse, who has a private practice in Boulder, Colo., noted that how CBT is conducted will depend on different variables, such as your goals, current mood state and functioning, and knowledge of bipolar disorder (or lack thereof). Generally, CBT focuses on helping individuals learn practical skills and strategies to decrease symptoms, improve social, academic, and occupational functioning, and improve quality of life, she said.
Brosse noted that in FFT, loved ones learn how bipolar disorder manifests in their family member, which “often results in more open and productive conversations about bipolar disorder, and more accurate attributions. For example, family members may be less likely to over attribute something to bipolar disorder (e.g., “You seem happy, you must be manic!”), and less likely to attack a person’s character (e.g., “You’re lazy”) when the person is actually depressed.”
FFT also includes helping families develop a concrete relapse prevention plan, and improve communication and problem-solving skills, which are especially vital during a mood episode or after a recent one, Brosse said.
Interpersonal and Social Rhythm Therapy (IPSRT) is recommended as a third-line treatment and also might be helpful for depressive episodes, Michalak said. IPSRT was specifically developed to treat bipolar disorder. According to Fink, “IPSRT is a variation on…interpersonal therapy, which focuses on the work of grieving for the loss of the ‘healthy self,’ and then it integrates the role of interpersonal conflict and events as risks or protective factors for mood episodes.” The primary goal, she said, is to maintain routines and rhythms in your daily life and interactions with others.
In addition, mindfulness-based cognitive therapy (MBCT) has shown some benefits in reducing depressive and anxiety symptoms in bipolar disorder, Fink said. Also, “while not specifically identified as effective in bipolar disorder, dialectical behavior therapy (DBT) is commonly adapted in work with those living with bipolar disorder because of the support it provides for both mood regulation and interpersonal effectiveness.”
Substance use disorders also commonly co-occur with bipolar disorder, so it’s vital to treat these conditions, along with any medical conditions, Fink added.
Importantly, these treatments are in addition to taking medication, and there’s currently no therapy that helps with mania, Michalak said.
How to Find Professional Help
To find a therapist, Fink recommended starting with your primary care provider, a local mental health association, a medical center with an outpatient psychiatry department, or an organization such as the Depression and Bipolar Support Alliance (DBSA) or National Alliance on Mental Health (NAMI). If you have insurance, Fink also noted that it’s important to ask your insurance company about coverage and providers.
Because finding therapists who specialize in the above treatments can be tough, Brosse recommended asking therapists these questions: “Can you tell me about your experience treating people with bipolar disorder? I’m looking for a therapist who can help me learn all the ins-and-outs of my bipolar disorder, and can give me specific skills to help me better manage my moods and prevent relapse. Do you work in this way?”
Finding the right therapist for you can take time. The key is to pick someone you feel comfortable with who has experience treating people with bipolar disorder. Keep in mind that it’s totally normal to work with several therapists before finding a therapist you like.
According to Michalak, until recently, research hadn’t focused much on self-management techniques as a complement to medication and psychotherapy. Self-management techniques are defined as: “the plans and/or routines that a person with bipolar disorder uses to promote health and quality of life,” she said.
Michalak and colleagues are conducting this kind of research—specifically focusing on web-based programs and applications. For instance, they’ve used some of their research findings to develop the website http://www.bdwellness.com, which features strategies to successfully manage bipolar disorder. Michalak believes that such resources are especially helpful when they’re co-designed by people with lived experience with bipolar disorder, and include social support and interaction.
Brosse also underscored that individuals with bipolar disorder can do so much in effectively managing the condition. You can start by looking for patterns around your mood episodes—and reducing your risk. For instance, you’ve realized that transitions trigger your episodes. When a transition is coming up—moving, starting a new job—you focus on “decreasing other risk factors and increasing protective factors.” Maybe, Brosse said, you see your therapist more often, return to therapy, or start therapy. Maybe you’re especially intentional with keeping a consistent sleep-wake schedule, not drinking alcohol, and taking more frequent walks.
As a whole, you might cultivate supportive relationships, eat nutrient-rich foods, and exercise, she said.
You also can use various skills, such as “opposite action,” Brosse said. For instance, when people with bipolar disorder get depressed, they tend to withdraw from others and do less. In this case, the opposite action is to “activate,” and keep social engagements on your calendar, exercise, and engage in tasks that give you a sense of accomplishment. On the other hand, during mania, the opposite action is to “de-activate,” decelerating your impulsivity and goal-directed behavior. This might look like disengaging from people and projects, sitting in silence in a dark room, and sleeping, she said.
Brosse also wanted readers to know that sometimes you can do all the right things, and a depressive, manic, or hypomanic episode still surfaces. This is when it’s critical to practice self-compassion (or have compassion for your loved one).
Be kind, patient, tender, and gentle with yourself—yes, similar to how you’d treat a friend or child. You deserve these things, even when you’re convinced you deserve the exact opposite.
Fink suggested tracking your mood (and, like Brosse above, regulating your sleep). “Apps are available for both of these and may be helpful for some people.” A favorite app of her patients’ is eMoods. She’s also recommended T2 Mood tracker, and noted that Moodtrack is a social media kind of platform that you can use only for yourself or share (by following others and having followers).
Fink emphasized the importance of speaking up with your treatment providers if something isn’t working for you. After all, “you can try other things.” Also, “sometimes, what is working at one point won’t continue to be needed, or won’t work as well— and a changing or evolving treatment plan is much more the rule than the exception.”